New SHM researcher: Sonia Boender
Could you tell us a little about your background?
After my first degree in Health Science, I followed a Master’s course in Health Science, specialising in infectious diseases and public health at the Vrije Universiteit Amsterdam. During my Master’s degree, I did a placement at PharmAccess, looking into barriers to access to HIV care in children in Uganda. This was the start of my interest in HIV. I find it very interesting to look at the relationship between health and society. This is particularly relevant in the field of HIV where extensive political efforts, donations and activism led to HIV treatment becoming available in Africa. Nonetheless, it remains a disease where much still needs to be done.
After my Master’s degree, I studied International Public Health at the Liverpool School of Tropical Medicine because I wanted to further develop my skills in international public health. This meant I became specialised in two areas, each with a different focus; in one, the starting point is the disease and in the other you start with the problem itself, such as infant mortality. After having studied both angles, I embarked on my PhD programme.
You were awarded your PhD degree in May. What did your PhD research entail?
The research was part of a large cohort study in six countries involving adults and children on HIV treatment, the PanAfrican Studies to Evaluate Resistance (PASER) and Monitoring Antiretroviral Resistance in Children (MARCH). My PhD research investigated resistance to HIV treatment in Africa, in both children and adults. I looked at the long-term effect of the increased availability of HIV treatment and any associated resistance development. Because, in Africa, HIV treatment is standardised and there are also limited diagnostic laboratory tests available, there is a far greater risk of HIV resistance to treatment.
The main finding of my research was that, in general, HIV therapies work very well in Africa, but that the virus has developed increasing resistance to the existing drugs over the years. It is therefore important to closely monitor treatment and make the switch to different medication in time, particularly since resistant strains of HIV can be passed on to a partner or from a mother to an infant. In our study, we saw that children in particular were increasingly becoming infected with a resistant HIV strain, as a result of which the standard treatment was no longer effective. Successfully treating HIV infections in children and adolescents remains a challenge.
To carry out my PhD research, I was regularly in African countries, such as Nigeria, Uganda and South Africa, visiting clinics and conferences. However, I also carried out a lot of my work from a distance, a little like the work done at SHM where we are in contact with HIV treating physicians in many difference clinics and we use the collected data to look at the effect of treatment. I particularly enjoy this aspect: instead of working within a clinical trial setting, collecting data from daily practice and subsequently looking for associations between data and practice.
What is it about the work at SHM that interests you?
After my PhD, I wanted to continue working on HIV, as I find it a fascinating subject with so many different aspects. As I said earlier, I like the way in which research at SHM is carried out, working with observational data instead of within a trial set-up. I was also drawn to the challenge of working with larger datasets. So, it was basically a combination of subject and methodology that attracted me to SHM. However, I was also keen to have the chance to examine the same subject in a different context, in this case the Netherlands. At the same time, SHM is also involved in international collaborations, so I won’t completely lose the international aspect. I’m also very excited by the fact that SHM is in direct contact with the field, such as patient organisations and the National Institute for Public Health and the Environment (RIVM). This gives the work an extra dimension besides just carrying out research.
What will you are working on at SHM?
Initially I am going to be working on the annual Monitoring Report. I have already begun by looking at the therapies available in the Netherlands. It is interesting to see that we have a far broader therapeutic arsenal in the Netherlands than in African countries. As for my PhD research, I will be looking at the outcomes of these treatments, the virological outcomes, resistance and anything else I happen to come across. Now that I’ve started work on the Monitoring Report, more and more questions are arising which I hope to be able to investigate further in the future.
You mention that the therapeutic arsenal in the Netherlands is far broader than in Africa. Do you often find yourself comparing the Netherlands with African countries?
Yes, I do it quite often. While there are many differences, it’s also interesting to see that there are similarities too. For example, everyone is trying to provide the optimum care with the available drugs and budget. In the Netherlands, however, treatment is far more tailored and far more laboratory tests are carried out. Furthermore, here it is possible to look more than just HIV, such as comorbidities.
So you’ve just started analysing the data for the Monitoring Report. Can you say anything about the way in which SHM works with the data?
Yes, absolutely! I’ve noticed, for example, that the approach at SHM is very thorough and that the data are of very high quality. Furthermore, the database and the data analysis are not just a means to an end, but actually an important topic in itself. I also enjoy the challenge of coding in a way that ensures that your research is reproducible and that the codes for each dataset are properly described. Moreover, there are so many observations and people in the SHM database, that it’s not possible to check your coding manually; this makes it even more important to programme properly to ensure everything is checked automatically.
Where do you see yourself in the future?
I’m interested in many different things, besides HIV, although I’ve noticed that now that I’ve been working on the subject for a while, my knowledge is increasing in both breadth and depth. Of course, I can imagine translating my skills to other infectious diseases such as hepatitis B and C, something I wouldn’t rule out.
But I am particularly keen to continue growing as an epidemiologist. As the volume of available data grows, particularly now that electronic patient records are becoming more common, the challenge in the future will be to ask the right questions and investigate these questions as thoroughly as possible. While I think this is very important, I would also like to combine this with ‘softer’ subjects such as the social and psychosocial aspects. I think it’s important to keep these aspects in mind, so that we are not only looking at whether or not a person takes their pill, but why they have or haven’t taken their pill, or why they are or aren’t linked to care. I hope to always be able to include this extra dimension in my work.